关于慢性疼痛长期阿片类药物治疗的数据很少

美国医疗保健研究与质量局（AHRQ）的一份报告显示，慢性疼痛的长期阿片类药物治疗根据剂量的高低可能会有导致严重危害的风险，但相关证据很少。

美国俄勒冈健康与科学大学太平洋西北地区循证实践中心/华盛顿大学的Roger Chou博士及其同事称，这份报告旨在解答关于长期阿片类药物治疗四大方面的问题：疗效以及较之非阿片类药物的相对疗效、危害和不良事件、剂量策略、风险评估与风险降低策略。这份报告主要是基于39项独立研究的结果，但由于少有研究符合纳入标准，这四个方面的许多关键问题都没有得到解答，特别是关于疗效和相对疗效的所有关键问题都没能解答。除一项研究外，其他所有解答了某个关键问题的研究都为低证据强度。

 

Roger Chou博士

关于危害和不良事件的研究显示，在初级医疗保健中，确诊为阿片类药物滥用的发生率为0.6%~8%，阿片类药物依赖的发生率为3.1%~26%。异常药物相关行为的发生率为5.7%~37.1%。长期阿片类药物治疗与药物滥用、用药过量、骨折、心肌梗死以及性功能障碍指标相关。剂量越高，发生这些结局的风险就越高。

作者发现，评估剂量策略与严重危害风险之间相关性的研究非常少。有一项研究显示，在退伍军人组成的人群中，美沙酮的死亡风险低于长效吗啡，这与我们通常的预期恰恰相反。多项研究表明，对于接受长期阿片类药物治疗的患者，芬太尼口腔或鼻腔给药在治疗急性疼痛方面更有效，不过这些研究主要关注的是短期结局。研究者没有找到相关研究来解答风险评估与风险降低策略方面的关键问题。

作者写道，虽然证据的确指向长期阿片类药物治疗的剂量越高，发生严重危害的风险就越高，但“仍需开展更多的研究以了解长期效益、药物滥用和相关结局的风险、不同阿片类药物处方方法和风险降低策略的有效性。”

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By: LUCAS FRANKI, Internal Medicine News Digital Network

Long-term opioid treatment for chronic pain may carry risk for serious harm depending on the dosage, but evidence is minimal at best, a report from the Agency for Healthcare Research and Quality suggests.

The report sought to answer key questions about long-term opioid treatment in four categories: effectiveness and comparative effectiveness with nonopioids, harms and adverse events, dosing strategies, and risk assessment and risk mitigation strategies. In the report, which was based on the results of 39 separate studies, many key questions in all categories were unaddressed because of a lack of studies meeting inclusion criteria, and no key questions were addressed under effectiveness and comparative effectiveness. All but one that addressed a key question had low strength of evidence.

Dr. Roger Chou

Relevant studies for harms and adverse events found that rates of diagnosed opioid abuse ranged from 0.6%-8% and dependence rates were 3.1%-26% in primary care settings. Abnormal drug-related behavior rates occurred in 5.7%-37.1%. Long-term opioid treatment was associated with increased risk of abuse, overdose, fracture, myocardial infarction, and markers of sexual dysfunction. Higher doses also were associated with increased risk of those outcomes, reported Dr. Roger Chou and his associates at the Pacific Northwest Evidence-based Practice Center at Oregon Health and Science University, Portland, and the University of Washington, Seattle.

The report’s authors found very few studies relating dosing strategies to risk for serious harm. One study found that methadone had a lower mortality risk than did long-acting morphine in a veteran population, the opposite of what would normally be expected, according to the agency. Multiple studies showed that buccal or intranasal fentanyl was more effective in treating acute pain of patients who were undergoing long-term opioid treatment, but these studies focused on short-term outcomes only. No relevant studies could be found to answer key questions about risk assessment and mitigation strategies.

While evidence does point toward a dose-based increase in serious harm from long-term opioid treatment, “more research is needed to understand long-term benefits, risk of abuse and related outcomes, and effectiveness of different opioid prescribing methods and risk mitigation strategies,” the authors wrote.